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258 NE 92 St (2)a) .( 6. Passed Ins ec r o e ) I ii Failed Correction Needed Re- Inspection Fee ($75) No Additional Inspections can be scheduled re- inspection fee is paid. until i nspec tiofN umb e r IN Inspection Date: 05/16/2006 Inspector: Levrack, James Owner: MILLER, WAYNE Job Address: 258 92 Street NE Project: <NONE> Monday, May 15, 2006 Miami Shores Village, FL 33138- Contractor: WP SEPTIC TANK CO INC Building Department Comments Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 os Block: m)t :N be FL2o95 -296 Permit Type: Imported Permit Inspection Type: Landscaping Work Classification: Drainfield Phone Number (305)606 -6450 Parcel Number 1132060133390 Lot: Phone: 305 -620 -6320 Page 2 of 2 /4 6( -- Passed Inspector - J ' Com ent / 1./ Failed Correction Needed Re- Inspection Fee ($75) No Additional Inspections can be scheduled re- inspection fee is paid. until nspectron ,,Num rm 2005=296 Inspection Date: 05/16/2006 Inspector: Levrack, James Owner: MILLER, WAYNE Job Address: 258 92 Street NE Project: <NONE> Miami Shores Village, FL 33138- Contractor: WP SEPTIC TANK CO INC Building Department Comments Monday, May 15, 2006 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Block: Permit Type: Imported Permit Inspection Type: Final Work Classification: Drainfield Phone Number (305)606 -6450 Parcel Number 1132060133390 Lot: Phone: 305 - 620 -6320 Page 2 of 2 �-4 NOV o .? 2005 MIAMI SHORr,S VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Date (0131 ( 05 Type lnsp'n�t 1 - 4g::. Permit No. PC-OE — 2 - 9 • Name ,ctiT� -f?� I t■t- 2_ -� aeDle Address Z Company P . 5 � � f C 74 ►� _ Phone # ( 305) C=.2-0 —a3 Z, Inspection Date Approved Correction Re- Insp'n Fee STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: [ ]New System [ ]Existing System [ ]Holding Tank [ ] Innovative Other [ X ]Repair [ ]Abandonment [ ]Temporary [ NA ] APPLICANT: Wayne Miller AGENT: SR0890743, PONDER WALLACE PROPERTY STREET ADDRESS: 258 NE 33138 LOT: 4/5/6 BLOCK: 25 SUBDIVISION: Miami Shores No. 1 [Section /Township /Range /Parcel No.] PROPERTY ID #: 11- 3206 - 013 -3390 [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME PERIOD. ANY CHANGE IN MATERIAL FACTS WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE OR LOCAL PERMITTING REQUIRED FOR PROPERTY DEVELOPMENT. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ]Gallons SEPTIC TANK MULTI- CHAMBERED /IN SERIES: [Y ] A [ 0 ]Gallons MULTI - CHAMBERED /IN SERIES: [Y ] N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @ [0 ]DOSES PER 24 HRS # PUMPS[ 0 ] D [ 300 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ 0 ]SQUARE FEET SYSTEM A TYPE SYSTEM: [ N ]STANDARD [ N ]FILLED [ N ]MOUND [ N ] I CONFIGURATION: [ N ]TRENCH [ N ]BED [ N ] N F LOCATION TO BENCHMARK: Top of Bottom Floor EL: 12.6' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 2.3 ] [ FEET ] [ BELOW] BENCHMARK /REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 5.0 ] [ FEET ] [ BELOW] BENCHMARK /REFERENCE POINT L D FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIRED: [ 32.0 ] INCHES OTHER REMARKS: 1 - Existing 900 gal septic tank to remain. 2 - Install 300 sf of drainfield in bed configuration. 3 - Invert elevation of drainfield to be no less than 8.13' NGVD. 4 - Bottom of drainfield elevation to be no less than 7.63' NGVD. This permit is NOT for Addition(s). SPECIFICATIONS BY: Heybeck, Nicholas TITLE: � -. 1; c., , � S• ��Z -�, S,�P- c.;c, t,1 APPROVED BY: Heybeck, Nicholas TITLE: Dade CHD DH 4016, 03/97 (Obsoletes previous editions which may not be used) (Stock Number: 5744- 001 - 4016 -0) ( ostds_cons_4016 -1) CENTRAX #: 13 -SG- 26363` DATE PAID: FEE PAID : $ RECEIPT . OSTDSNBR : 05 -2934- -R DATE ISSUED: 9/6/05 EXPIRATION DATE: 12/5/05 Page 1 of 2 BUILDING PERMIT APPLICATION FBC 2001 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami _ Florida 33138 Tel Q - . cut 5) 756.8972 AiL r Permit No. Pc_.05 aster Permit No. Permit Type (circle): Building _ Electrical A 1 Plumbing Mechanical Roofing f ► Owner's Name (Fee Simple Titleholder) `�' ���1 Q NA L` 1 fz.Y Phone # %G5 Owner's Address L5 s N 1'_ 9 4.. S '• City \ A'rnt' S� o� Qg State . L Tenant/Lessee Name Sa ypl. e Phone # Sa `r.L Zip 33 I • $ Job Address (where the work is being done) 50 P71. e City Miami Shores Village County Miami -Da Zip Is Building Historically Designated YES NO Contractor's Company Name v. P S i , t c_ Phone # .7t9 .-- 20 `WSJ 2b Contractor's ddress / 7 Z 3S /1/11 V/ z C , 3 37s City b Ov State /� Zip Qualifier 1 / G: C Q (� l-. / e p State Certificate or Registration No. 5 (,Qz..■. - C, Certificate of Competency No. Architect/Engineer's Name (if applicable) f/ / Phone # n $ Value of Work For this Permit hoc. Type of Work: Describe Work: Submittal Fee $ Permit Fee $ 1 7.E Total Fee Now Due $ 403 .10 (Continued on opposite side) Square Footage Of W : "O ❑Addition ❑Alteration ❑New [� Repair/Rriplac9 � i ❑ Demolition New &2 � lam ©ra it"4: P * * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** CCF $ • CO /CC Notary $ Training/Education Fee 5 O 120 Technology Fee $ 4. 40 Scanning $ 3- Ca Radon $ Zoning Bond $ 30 • 00 Code Enforcement $ Structural Plan Review. $ 1 1303 Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Owner or Agent The foregoing instrument was acknowledged before me this a8 day ofapkinizr, 2OO by who is . ersonally known to me or who has produced A Jiff t tary Public - State of Florida r� ,. •" TJIy omm�fon E cµtesMar16,2008 - . F {IP C y : *,Gemreit # 1)* * °„ °'' Bonded By National Notary Assn. NO S Print: My Com ************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** APPLICATION APPROVED BY: Chc 05/13/03 IVERA n and who did take an oath. day of NOTARY S Prin My * * * * * * * * * * * * * * * * * * * * * * ** Jl , 7 Contractor The foregoing instrument was acknowledged before me this �v , 20 by o me or who : .duced • ,,' • • • m �.. • . ., le s , L�irmssion # DD268491 * , *u4° * * g By National Notary Assn. as identificat * * * * * * * * * * * * * * * * * * * * * * * ** Engineer Zoning take an oath. * * * * * * ** : r xaniinei' ADDENDUM. TO BUILDING PERMIT APPLICATION (AN`ArPLICATION FOR BUILDING PERMIT MUST ACCOMPANY THIS ADDENDUM. IF A MASTER PERMIT_ HA OBTAINED, THE OWNER'S NOTARIZED SIGNATURE NEED NOT BE PRESENT ON SUBSEQUENT APPLICATIC PLUMBING LAWN SPRINKLER SYSTEM. GAS RANGE METER SET (GAS) GAS P I P I N_ ELECTRICAL MECHANICAL v I I UNIT FEE ITEM! SWITCH CUTLETS UNIT FEE ITEM SPACE HEATERS UNIT !TEM BADE LIGHT OUTLETS CENTRAL HEATING BIDET RECEPTACLES A/C (WIND) DISHWASHER SERVICE TEMPORARY I A/C (CENTRAL) DISPOSAL DRINKING FOUNTAIN SERVICE SIZE IN ALPS DUCT WORK FLOOR DRAIN SERVICE REPAIR/PETER CHANGE REFRIGERATION APPLIANCE OUTLETS PROCESS AND PRESS PIPING GREASE TRAP INTERCEPTOR RANGE TOP UNDERGROUND TANKS LAVATORY OVEN ABOVE GROUND TANKS LAUNDRY TRAY WATER HEATER U.F. PRESSURE VESSELS CLOTHES WASHER MOTORS C- 1 Ha STEAM BOILERS [ SHOWER MOTORS OVER 1- 3 HP HOT WATER BOILERS SINK, POT /3 COMP. MOTORS OVER 3- 5 HP MECHANICAL VENTILATION SINK, RESIDENCE MOTORS OVER 5- 8 HP TRANSPORTING ASSEMBLIES SINK, SLOP MOTORS OVER 8- 10 HP ELEVATORS/ESCALATORS TEMPORARY WATER CLOSET MOTORS OVER 1C- 25 HP FIRE SPRINKLER SYSTEMS URINAL MOTORS OVER 25-100 HP COOLING TOWERS I WATER CLOSET MOTORS OVER 100 HP l VIOLATION INDIRECT WASTES A/C WINDOW 1 REI1NSPECTJON WATER SUPPLY TO: AIR CONDITIONERS A/C UNIT STRIP HEATER FIRE SPRINKLER GENERATORS TRANSFORMERS HEATER -NEW INST. GENERATORS . TRANSFORMERS HEATER - REPLACE GENERATORS TRANSFORMERS LAWN SPRINKLER -WELL I I SPECIAL PURPOSE I I SWIMMING POOL (OUTLETS COM4,ERC I AL WATER SERVICE I SIGN TUBES SEWER CONNECTIONS 'SIGN TRANSFORMERS UTILITY -SEWER SIGN TIME CLOCK UTILITY -WATER FIXTURES SEPTIC TANK ANTENNA RELAY TELEVISION OUTLETS INF,FthD4 TILE/RES. s �, ' VIOLATION PUhP & ABANDON SEPTIC TANK REINSPECTION SOAKAGE PIT CU. FT. CATCH BASIN DISCHARGE WELL I DOMESTIC WELL I I AREA DRAIN I l ROOF INLET SOLAR WATER HEATER I I FIRE STANDPIPE I 1 POOL PIPING 1 I ADDENDUM. TO BUILDING PERMIT APPLICATION (AN`ArPLICATION FOR BUILDING PERMIT MUST ACCOMPANY THIS ADDENDUM. IF A MASTER PERMIT_ HA OBTAINED, THE OWNER'S NOTARIZED SIGNATURE NEED NOT BE PRESENT ON SUBSEQUENT APPLICATIC PLUMBING LAWN SPRINKLER SYSTEM. GAS RANGE METER SET (GAS) GAS P I P I N_ ELECTRICAL MECHANICAL v I I CONSTRUCTION PERMIT FOR: [ ]New System [ ]Existing System [ ]Holding Tank [ ] Innovative Other [ X ]Repair [ ]Abandonment [ )Temporary [ NA ] APPLICANT: Wayne Miller AGENT: SR0890743, PONDER WALLACE PROPERTY STREET ADDRESS: 258 NE Ave FL 33138 LOT: 4/5/6 BLOCK: 25 SUBDIVISION: Miami Shores No. 1 [Section /Township /Range /Parcel No.] PROPERTY ID #: 11- 3206 - 013 -3390 [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME PERIOD. ANY CHANGE IN MATERIAL FACTS WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE OR LOCAL PERMITTING REQUIRED FOR PROPERTY DEVELOPMENT. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ]Gallons SEPTIC TANK MULTI - CHAMBERED /IN SERIES: [Y ] A [ 0 ]Gallons MULTI - CHAMBERED /IN SERIES: [Y ] N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @ [0 ]DOSES PER 24 HRS # PUMPS[ 0 ] D [ 300 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ 0 ]SQUARE FEET SYSTEM A TYPE SYSTEM: [ N ]STANDARD [ N ]FILLED [ N ]MOUND [ N ] I CONFIGURATION: [ N ]TRENCH [ N ]BED [ N ] N F LOCATION TO BENCHMARK: Top of Bottom Floor EL: 12.6' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 2.3 ] [ FEET ] [ BELOW]BENCHMARK /REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 5.0 ] [ FEET ] [ BELOW]BENCHMARK /REFERENCE POINT L D FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIRED: [ 32.0 ] INCHES OTHER REMARKS: 1 - Existing 900 gal septic tank to remain. 2 - Install 300 sf of drainfield in bed configuration. 3 - Invert elevation of drainfield to be no less than 8.13' NGVD. 4 - Bottom of drainfield elevation to be no less than 7.63' NGVD. This permit is NOT for Addition(s). SPECIFICATIONS BY: Heybeck, Nicholas TITLE: r 4 .- . 1, 1; w ; � APPROVED BY: Heybeck, Nicholas STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT TITLE: DATE ISSUED: 9/6/05 EXPIRATION DATE: 12/5/05 DH 4016, 03/97 (Obsoletes previous editions which may not be used) (Stock Number: 5744- 001 - 4016 -0) [oseds_cons_4016 -1] CENTRAX #: 13 -SG -26363 DATE PAID: FEE PAID : $ RECEIPT . OSTDSNBR : 05 -2934- -R Dade CHD Page 1 of 2 Site Plan submitted by: 'Ian Approved 3y STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number PART II - SITE PLAN n block represents 5 feet and 1 inch = 50 feet. H 4015, 10/96 (Replaces HRS-H Form 4015 which may be used) kid( Number: 5744 -002- 4015 -6) j ys /IAA in n .:. ..,s: A 1 CI .r a '74 I ,( A'04 e INAM Signature Not Approved rw ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT A o ; Title Date County Health Department Page 2 of 3 APPLICANT: LOT: PROPERTY ID 0: SITE EVALUATED BY: MATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS BLOCK: TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER_QVALIFIED PERSON _. ENGINEER'S MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN: [`,)'YES [ ] TOTAL ESTIMATED SEWAGE FLOW: ,-, , GALLONS AUTHORIZED SEWAGE FLOW: ' - 5' GALLONS UNOBSTRUCTED AREA AVAILABLE: '' SQFT C'BENC RREFERENCE POINT LOCATION: ELEVATION OF PROPOSED SYSTEM SITE IS THE MINIMUM SETBACK WHICH SURFACE WATER: ;! / t FT WELLS: PUBLIC: ` / A FT BUILDING FOUNDATIONS: SOIL PROFILE INFORMATION SITE 1 ' 1 SUBDIVISION: CAN BE MAINTAINED FROM THE DITCHES /SWALES: LIMITED USE: F / FT FT PROPERTY LINES: SITE SUBJECT TO FREQUENT FLOODING: [ ] YES 10 YEAR FLOOD ELEVATION FOR SITE: Munsell 0/Color USDA SOIL SERIES: Texture R'f,Q ivy; J• Depth to to to to to to to to to OBSERVED WATER TABLE: i, INCHES [ABOVE / ESTIMATED WET SEASON WATER TABLE ELEVATION; HIGH WATER TABLE VEGETATION: [ ] YES [A/NO SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: :1i^ '41 DRAINFIELD CONFIGURATION: [ ] TRENCH [ `,J BED REMARKS /ADDITIONAL CRITERIA: AGENT: PERMIT 0 [ /Township /Range /Parcel No on Tax ID Number], NO NET USABLE AREA AVAILABLE: /1', ACRES PER DAY [„_ESIDENCE _TS TS- ABLE2, / OTHER -TABLE 2] PER DAY [1500 GPD /ACRE 50 _ 0 GPD ACRE] UNOBSTRUCTED AREA REQUIRED: � --) SQFT ," r / r r [INCHES /(FTJ [ABOVEr44001 _$ ' /REFERENCE POINT [ :4'NO FT MSL /NGVD PROPOSED SYSTEM TO THE FOLLOWING FEATURES: 41/./ t9 FT NORMALLY WET? [ ] YES [ t]F - NO PRIVATE: _LLA1 FT NON- POTABLE: __„ " , rt' /0 FT POTABLE WATER LINES: fC FT 10 YEAR FLOODING? [ ] YES [-r NO SITE ELEVATION: :(., FT MSL /NGVD SOIL PROFILE INFORMATION SITE 2 Munsell it/Color Texture Depth 7,.' V Q ._! ( i , A !--., {'; L �4) A t ' to ' / r t • i -7;7 �� to to USDA SOIL SERIES: to to to to i to ,BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT] X 1 ,t 0 INCHES [ ABOVE /,BELOW ] EXISTING GRADE. MOTTLING: [ ] YES []NO DEPTH: 4 / . /[} INCHES r'1 .U1 DEPTH OF EXCAVATION: %, , INCHES ] OTHER (SPECIFY) DATE: Miami Shores Village 10050 NE 2nd Avenue Phone: 305 - 795 -2204 Printed: 10/3/2005 Plumbing Permit Permit Number: PL2005 -296 Applicant: CATHERINE VERA RESEK Owner: RESEK CATHERINE VERA JOB ADDRESS: 258 NE 92 ST Contractor W P SEPTIC TANK CO INC Local Phone: 305 - 620 -6320 Parcel # 1132060133390 Contractor's Address: 17235 NW 12 CT Page 1 of 1 Legal Description: MIAMI SHORES SEC 1 AMD PB 10 -70 LOT 5 & W1/2 OF LOT 4 & E1OFT OF LOT 6 Fees: Description Amount FEE2005 -13026 Building Fee $175.00 FEE2005 -13027 CCF $0.60 FEE2005 -13028 Training and Education Fee $0.20 FEE2005 -13029 Technology Fee $4.40 FEE2005 -13030 Scanning Fee $3.00 FEE2005 -13031 Builders Bond $300.00 Total Fees: $483.20 Total Fees: $483.20 Total Receipts: $0.00 Permit Status: APPROVED Permit Expiration: 4/1/2006 Construction Value: $1,000. Work: INSTALL NEW 300 SQ FT DRAINFIELD Signed: (INSPECTOR) CCT 2 O PAID In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility for all work done by either myself, my agent, servants or employes. Signed: (Contractor or Builder) BY: 'Permit No 4S Date Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. Owner's Name and Address _____ ® � 1- Registered Architect and /or Engineer Employing Plumber's Name Location and Legal Description Lot 4 0 a 1. New Building Size Septic Tank Feet of Drain Tile Nature of Water Supply: City —Well Amount of Permit $ STATE OF FLORIDA, COUNTY OF DADE. ss. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Street and Number where work is to be performed —No State work to be performed and purpose of building (By Floors) Block Street Remodeling Addition � /. Repairs No. of Stories r / �-.,. Type of Tank r_ZC Capacity Gals Dist. Feet of Tank or Drain Field from Well _._ Size of Soakage Pit ( Signed) P1u$#bing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are required by the Act. The undersigned agrees to employ only such sub - contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. (Signed) No �4� No Street Subdivision_ a., Gam— Street_ My Commission Expires Notary Public, State of Florida ?-? Master Plumber. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty materials and /or workmanship. CLOSETS BATH TUBS SHOWERS LAVA- TORIES SINKS SLOP SINKS LAUNDRY TUBS URINALS' CATCH BASIN FLOOR DRAIN DRINKING FOUNT'NS TOTAL FIXTURES CONTR. LIST CHECK SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR HEATER DEEP WELL SPRKLR. SYSTEM SWIM'G POOL CONTR. LIST CHECK 'Permit No 4S Date Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. Owner's Name and Address _____ ® � 1- Registered Architect and /or Engineer Employing Plumber's Name Location and Legal Description Lot 4 0 a 1. New Building Size Septic Tank Feet of Drain Tile Nature of Water Supply: City —Well Amount of Permit $ STATE OF FLORIDA, COUNTY OF DADE. ss. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Street and Number where work is to be performed —No State work to be performed and purpose of building (By Floors) Block Street Remodeling Addition � /. Repairs No. of Stories r / �-.,. Type of Tank r_ZC Capacity Gals Dist. Feet of Tank or Drain Field from Well _._ Size of Soakage Pit ( Signed) P1u$#bing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are required by the Act. The undersigned agrees to employ only such sub - contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. (Signed) No �4� No Street Subdivision_ a., Gam— Street_ My Commission Expires Notary Public, State of Florida ?-? Master Plumber. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty materials and /or workmanship.